Debriefs help make sense of adverse events

Where: Delaware-based Christiana Care Health System Inc., which has 2 teaching hospitals
in Newark and Wilmington with a total of more than 1,100 beds.

The issue: Enabling clinicians and other staff to discuss serious adverse clinical
events soon after they occur.

Background

When an adverse event happens during a patient's hospitalization, an emotional ripple
percolates to clinicians and other staff members. “As humans, we are fallible,
and we really own these events. When something happens, it's our obligation to bring
it forward, raise our hand, and then to learn from it and share the learnings from
it, change our systems, and then go further and make changes within the entire organization,”
said Kathleen McNicholas, MD, JD, medical director of performance improvement at Christiana
Care.

To systematically work toward this goal, Christiana Care launched a debriefing process
in June 2009, formally designating the postevent period as a time to find the facts
and implement improvements.

How it works

Debriefs are usually at least an hour in length and occur anywhere from 24 to 72 hours
after the event. “Primarily, they're gathering the facts and what happened,
and that's where the learning and the understanding come in,” said Michele
Campbell, RN, MSM, vice president for patient safety and accreditation.

Depending on where the event occurs and who was involved in the patient's care, the
debrief gathers related staff members from across the health system's 9 service lines.
“A lot of these events are not just about 1 department or 1 service line because
of the way care is delivered,” Ms. Campbell said. “You have the attending
physician, but you have the specialists caring for the patient as well, so we do look
at that horizontal work, not only vertical.”

Dr. McNicholas said the debriefing process is the antithesis of the ABC technique
she often experienced as a cardiac surgeon—assess, blame, and crucify. “It
is not an inquisition; it's a very supportive environment....I think people come in
very nervous, in large part because it's something that's unknown to them, but we
also want to hear everybody speak, so we start out introducing everybody in a friendly
environment,” she said.

Results

Christiana Care has now held more than 200 debriefs covering a range of issues, such
as medication errors, patient falls, and unanticipated deaths, and has seen favorable
patient safety results. For example, preventable patient harm (e.g., hospital-acquired
infections, non-ICU code blues, and several other safety indicators) decreased by
60% from 2010 to 2014, according to an article published in January by The Joint Commission Journal on Quality and Patient Safety.

The debriefs have led to process improvements in several domains. For instance, the
health system changed its approach to airway codes by creating airway carts with standardized
supplies and assigning multiple trauma disciplines to respond immediately in case
a surgical airway is needed, Ms. Campbell explained. In addition, special badges now
allow clinicians to call for a code team without having to leave the patient and go
to a phone. “We deployed the badges in areas where staffing was not as optimal
as it could be on, say, the night shift or some of the remote labs,” Ms. Campbell
said.

Challenges

Scheduling debriefs that involve 10 to 20 people can be a challenge, especially when
busy physicians need to be at the table, but there are workarounds, Dr. McNicholas
said. “If we make it a 6 a.m., everybody comes because the only excuse, really,
is that they like to sleep. And nobody wants to miss it because it is a deep and supportive
discussion.”

Another challenge is that debriefs and the preceding adverse events can cause uneasiness
among residents, so sometimes it's helpful to curtail the visibility of senior leadership
at the meeting and minimize open, emotionally charged conversation, Ms. Campbell said.

“When anyone is intimately involved in that particular event...those individuals
are hurting because they are the second victim, and we need to be hypersensitive to
that fact because they may walk out and feel differently than what we're thinking
they're feeling,” she said. “There have been instances where residents
have felt uncomfortable, but if that comes up, we do try to [address] that outside
of the debrief because not everybody feels comfortable talking about it.”

Next steps

Compared to when the debriefs first started, the criteria that necessitate a debrief
have narrowed a bit to include only the more substantial events that involve patient
harm, Ms. Campbell said. In less serious circumstances, unit-based care teams will
often engage in more informal, immediate huddles instead.

Looking forward, both Ms. Campbell and Dr. McNicholas, who currently facilitate the
debriefs, anticipate that the program will continue, although they are beginning to
think about succession planning. “Certainly, I think when the leadership is
engaged, that promotes change in culture as well as the process,” Ms. Campbell
said. “I'd like to see more physicians who would be able to step in and be
a facilitator among the service lines.”

Words of wisdom

“This takes a lot of courage. This is not for the faint of heart...[but] it
is driven by empathy because we all [can] see ourselves in the role of the person
who got caught at the sharp end and, particularly, in the role of our patients, who
someday could be us,” Dr. McNicholas said.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.